Provider Demographics
NPI:1164424990
Name:BUFORD, MALCOLM L JR (MD)
Entity Type:Individual
Prefix:
First Name:MALCOLM
Middle Name:L
Last Name:BUFORD
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 268838
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73126-8838
Mailing Address - Country:US
Mailing Address - Phone:918-619-4400
Mailing Address - Fax:918-619-4591
Practice Address - Street 1:591 E 36TH ST N
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74106-1812
Practice Address - Country:US
Practice Address - Phone:918-619-4888
Practice Address - Fax:918-619-4591
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2016-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK27926207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200297050AMedicaid
OKOKA101520Medicare PIN
ID11326701Medicare PIN
WA8428724Medicaid
000010162665OtherREGENCE BLUE SHIELD OF ID
WA807196600Medicaid